原產地聲明(中譯)
製造商、供應商、出口商、進口商應於出口發票或其他進口貨物之相關文件上，以英語保證以下內容：
本人【姓名與職位】為【製造商與出口商】【製造商】【出口商】【進口商】【供應商】（以上擇一適當者填寫），茲聲明本發票所載貨品係原產於【臺灣、澎湖、金門、馬祖個別關稅領域】【紐西蘭】（以上擇一適當者填寫），符合紐西蘭與臺灣、澎湖、金門、馬祖個別關稅領域經濟合作協定第3章之規定。
補充說明：
簽名：日期：
原產地聲明填寫說明
依據協定第3章第16(貨品申請適用優惠關稅待遇)規定，為獲得優惠關稅待遇，本文件應由出口商、製造商、供應商或進口商，以英語清晰並完整地填寫。
原產地聲明之「補充說明」欄位中應包括以下資訊（除非所列資訊已顯示在該聲明所涉貨品之出口發票上）：
export declaration
(a)貨品完整名稱；
(b)該貨品之稅則六位碼；
(c)已知之製造商
(d)進口貨品已知之進口商名稱；
(e)聲明貨品符合優惠關稅待遇之原產地規則–詳見附件2原產地證明書第6欄
DECLARA T ION OF ORIGIN
The producer, supplier, exporter or importer will certify (in English) on the face of the export invoice or other document relating to the goods as follows:
I…………………….. [state name and position] being
the ……………………………. [producer and exporter] [producer] [exporter]
[importer] [supplier] (insert only that which applies) hereby declare that the goods enumerated on this invoice are originating from [ the Separate Customs Territory of Taiwan, Penghu, Kinmen, and Matsu] [New Zealand] (insert only that which
applies) in that they comply with the provisions of Chapter 3 of the Agreement
between the Separate Customs Territory of Taiwan, Penghu, Kinmen, and Matsu and New Zealand on Economic Cooperation
Observations:
Signature: Date:
DECLARA TION OF ORIGIN INSTRUCTIONS
Pursuant to Article 16 (Treatment of Goods for which Preference is Claimed) of Chapter 3 of the Agreement, for the purposes of obtaining preferential tariff treatment this documen t must be completed legibly, in English and in full by the exporter, producer, supplier or importer.
The declaration of origin must include the following information in the
‘O bservations’ field of the declaration (unless such information already appears o n the export invoice in respect of the goods subject to the declaration):
(a)    a full description of the good(s);
(b) six digit Harmonized System Code for the respective good(s);
(c) the producer's name(s) if known;
(d) the importer's name(s) in respect of imported goods, if known; and
(e) the rule of origin under which the declarant claims the good(s) qualifies – see
certificate of origin instruction on Field 6.